-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
1/14
This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formattedPDF and full text (HTML) versions will be made available soon.
Hikikomori as a possible clinical term in psychiatry: a questionnaire survey
BMC Psychiatry2012, 12:169 doi:10.1186/1471-244X-12-169
Masaru Tateno ([email protected])Tae Woo Park ([email protected])
Takahiro A Kato ([email protected])Wakako Umene-Nakano ([email protected])
Toshikazu Saito ([email protected])
ISSN 1471-244X
Article type Research article
Submission date 24 February 2012
Acceptance date 12 October 2012
Publication date 15 October 2012
Article URL http://www.biomedcentral.com/1471-244X/12/169
Like all articles in BMC journals, this peer-reviewed article can be downloaded, printed anddistributed freely for any purposes (see copyright notice below).
Articles in BMC journals are listed in PubMed and archived at PubMed Central.
For information about publishing your research in BMC journals or any BioMed Central journal, go to
http://www.biomedcentral.com/info/authors/
BMC Psychiatry
2012 Tateno et al.This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.biomedcentral.com/1471-244X/12/169http://www.biomedcentral.com/info/authors/http://creativecommons.org/licenses/by/2.0http://creativecommons.org/licenses/by/2.0http://www.biomedcentral.com/info/authors/http://www.biomedcentral.com/1471-244X/12/169mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected] -
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
2/14
Hikikomori as a possible clinical term in psychiatry:
a questionnaire survey
Masaru Tateno1** Corresponding authorEmail: [email protected]
Tae Woo Park2
Email: [email protected]
Takahiro A Kato3
Email: [email protected]
Wakako Umene-Nakano4
Email: [email protected]
Toshikazu Saito1
Email: [email protected]
1 Department of Neuropsychiatry, Sapporo Medical University, School of
Medicine, South-1, West-16, Chuo-ku, Sapporo 0608543, Japan
2 Department of Psychiatry, Boston University School of Medicine and VA
Boston Healthcare System, 251 Causeway Street, Boston, MA 02114, USA
3
Department of Neuropsychiatry, Graduate school of Medical Sciences, KyushuUniversity, 3-1-1 Maidashi Higashi-ku, Fukuoka 8128582, Japan
4 Department of Psychiatry, School of Medicine, University of Occupational and
Environmental Health, Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka
8078555, Japan
Abstract
Background
The word hikikomori, the abnormal avoidance of social contact, has become increasingly
well-known. However, a definition of this phenomenon has not been discussed thoroughly.
The aim of this study is to gain a better understanding of the perception of hikikomori
amongst health-related students and professionals and to explore possible psychiatric
conditions underlying hikikomori.
Methods
A total of 1,038 subjects were requested to complete a questionnaire regarding hikikomori
phenomenon.
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
3/14
Results
While some differences in the perception of hikikomori do exist, all subjects tended to
disagree with the statement, hikikomori is NOT a disorder. Regarding the underlying
psychiatric disorders of hikikomori, approximately 30% of psychiatrists chose schizophrenia
as the most applicable ICD-10 diagnosis for hikikomori, whereas 50% of pediatricians choseneurotic or stress-related disorders.
Conclusions
An argument still exists regarding the relationship between hikikomori and psychiatric
disorders. We propose that the term hikikomori could be used to describe severe social
withdrawal in the setting of a number of psychiatric disorders.
Keywords
Hikikomori, Social withdrawal, School refusal, Psychiatric diagnosis, Developmental
disorders
Background
The word hikikomori was recently added to the Oxford Dictionary of English [1] where it
joins other words of Japanese origin such as otaku (person with obsessive interests) and
karoshi (death from overwork). It is defined as the abnormal avoidance of social contact,
typically by adolescent males. Hikikomori was first introduced to the public when a
Japanese psychiatrist, Tamaki Saito, published a book with this word in its title in 1998 [2].In his book Social Withdrawal (shakaiteki hikikomori): A Neverending Adolescence, Saito
defined hikikomori provisionally as those who withdraw entirely from society and stay in
their own homes for more than six months, with onset by the latter half of their twenties, and
for whom other psychiatric disorders do not better explain the primary causes of this
condition. Since then, the word hikikomori has been used widely in Japan and has more
recently been reported in the foreign media and discussed in medical journals by psychiatrists
from other countries [3-13]. Much of this attention occurred without a thorough discussion of
its precise definition [14-17].
In May 2010, a research group supported by the Japanese government published guidelines
for the assessment and treatment of hikikomori [18]. The guidelines defined hikikomori as
the following: A phenomenon in which persons become recluses in their own homes,
avoiding various social situations (e.g. attending school, working, having social interactions
outside of the home etc.) for at least six months. They may go out without any social contact
with others. In principle, hikikomori is considered a non-psychotic condition distinguished
from social withdrawal due to positive or negative symptoms of schizophrenia. However,
there is a possibility of underlying prodromal schizophrenia.
These guidelines were based on a number of studies including the analysis of 184 consecutive
hikikomori cases at five different mental health centers (Kondos survey cited in the
guidelines [18]; unpublished) , the investigation of hikikomori youths referred to psychiatricemergency services (Nakashimas survey cited in the guidelines [18]; unpublished), and a
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
4/14
nationwide survey conducted as a part of the WHO World Mental Health Initiatives (WMH-
J) [19]. The WMH-J survey selected subjects from voter registration lists in various parts of
Japan, interviewed a total of 4,134 respondents aged 2049 (response rate: 55.1%) and
demonstrated that a total of 1.2% had experienced hikikomori. They estimated that there are
232,000 ongoing hikikomori cases in Japan. Furthermore, in September 2010, the Cabinet
Office of the Japanese government published results of their study on hikikomori andreported that the number of hikikomori was estimated to be 236,000 [20]. These results
demonstrate that hikikomori is a common problem in Japan.
In this study, we conducted a questionnaire survey of hikikomori with 1,038 subjects.
Because psychiatrists and pediatricians tend to have the most clinical contact with hikikomori
individuals, we included additional questions regarding potential underlying psychiatric
conditions of hikikomori for the psychiatrists and pediatricians participating in the study. The
overall aim of this study is to gain a better understanding of the perception of hikikomori
amongst health-related students and professionals and to explore possible psychiatric
conditions underlying hikikomori.
Methods
Subjects
The subjects of this study were psychiatrists who work at one of three University hospitals
(Sapporo Medical University, Kyushu University, and the University of Occupational and
Environmental Health) or their affiliating hospitals, pediatricians who are on the electronic
mailing list of the Japanese Society of Psychosomatic Pediatrics, clinical psychologists who
are included in the electronic mailing list of the Society of Certified Clinical Psychologists in
the Hokkaido region of Japan, nurses of all 25 different clinical services at Sapporo MedicalUniversity Hospital, students at Sapporo Medical University including the School of
Medicine and the School of Health Sciences, and others who received invitations to this study
through the above-mentioned subjects. The three universities were selected as a study site
because three of the authors (MT, TAK and WUN) worked together for previous studies
[21,22]. These study subjects were chosen primarily to increase the response rate with the
belief that health-related students and professionals would have greater interest in this area of
study and that these subjects would be more responsive to the survey request. Demographics
of study subjects other than profession were not collected.
The total number of the respondents was 1,038 and a description of the respective groups is
shown in Table 1. Respondents were divided into five different groups: medical doctors
(psychiatrists and pediatricians), nurses, psychologists, students and others. The response rate
of each group was as follows: psychiatrists 85.1%, nurses 89.7% and students 79.5%.
Because two mailing lists used in this study contained a number of invalid addresses, it was
difficult to verify response rates of pediatricians and clinical psychologists. However, based
on the report by each mailing list manager, the response rate was estimated to be 60 percent
for both groups.
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
5/14
Table 1The summary of the results
Medical doctor (n=106) nurse
(n=595)
psychologist
(n=46)
student
(n=229)
others
(n=62)(psychiatrist / pediatrician)
(n=80 / n=26)
To be diagnosed as hikikomori, how
long do they withdraw from the
society and keep staying in their
home?
6.323.7
(6.853.9 / 4.692.3)
3.833.8 5.674.1 2.953.4 3.822.5
Hikikomori is NOT a disorder 2.701.1
(2.741.0 / 2.581.3)
2.611.1 2.801.0 2.861.1 2.811.2
Hikikomori persons shut themselves in
their room the while day and rarely see
their family
3.221.2
(3.201.2 / 3.271.2)
3.731.2 3.111.2 3.741.2 3.351.2
Hikikomori individuals sometimes go
out for grocery stores and bookstores
3.521.1
(3.571.1 / 3.421.1)
2.911.3 3.611.1 2.861.2 3.331.2
School refusal closely relates to
hikikomori
4.120.9
(4.110.9 / 4.151.0)
3.991.0 3.890.9 3.901.1 3.951.0
Recovery is possible in individualswith hikikomori
3.780.8(3.670.8 / 4.040.7)
4.000.9 4.130.8 4.260.8 4.080.9
Hikikomori is related to biological
factors such as psychiatric disorders or
developmental disorders
3.870.9
(3.860.8 / 3.851.1)
3.301.0 3.700.8 3.171.0 3.480.9
Hikikomori is related to psychological
factors such as bullying at school or
frustration at workplace
3.990.8
(3.910.7 / 4.230.9)
4.240.7 4.020.6 4.390.7 4.160.6
Hikikomori is related to social factors
such as family environment which
accepts the situation
4.020.7
(3.960.7 / 4.190.7)
4.030.8 3.850.7 4.160.8 3.870.7
Hikikomori is related to Japanese
society, culture or national
characteristics
3.611.0
(3.650.9 / 3.501.2)
3.161.1 3.300.9 3.401.0 3.181.0
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
6/14
The results are expressed as the mean standard deviation (SD). On the five-point Likert scale, score 5 means the strong agreement
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
7/14
Methods of data collection
The study authors created an online questionnaire and e-mailed the web link and login
password for the questionnaire page to collaborators. The site collaborators then distributed
the invitation e-mail to their colleagues. For nurses and students, a printed questionnaire was
distributed. Both the online and printed questionnaires took approximately 10 minutes tocomplete.
All subjects were requested to complete the questionnaire within the survey period between
May 1 and July 31, 2010.
Questionnaire
The questionnaire contained three types of responses: open responses (the length of social
withdrawal), responses on a five-point Likert scale and single choice responses (psychiatric
diagnosis) (Table 1). A Likert scale is a commonly used method for the measurement of
attitudes in survey studies [23,24]. The subjects were asked to rate their answers to a
statement using a five-point scale ranging from one, indicating strongly disagree, to five,
indicating strongly agree, with three representing a neutral response that neither agreed nor
disagreed with the statement. Additionally, psychiatrists and pediatricians were asked what
they felt would be the most applicable psychiatric diagnosis of hikikomori from the F codes
(blocks) in Chapter V of the ICD-10[25] (Table 2).
Table 2Psychiatric background of hikikomori
ICD-10 Chapter V Psychiatrists Pediatricians
(n=80) (n=26)
F2: Schizophrenia, schizotypal and delusional disorders 30.0% 3.8%F3: Mood (affective) disorders 2.5% 11.5%
F4: Neurotic, stress-related and somatoform disorders 16.3% 50.0%
F6: Disorders of adult personality and behavior 21.3% 3.8%
F7: Mental retardation 2.5% 0%
F8: Disorders of psychological development 17.5% 23.1%
Hikikomori is not a disorder 1.3% 0%
No idea 8.8% 7.7%
Psychiatrists and pediatricians were requested to select the most applicable psychiatric
diagnosis of their experienced hikikomori cases according to the ICD-10
Ethical matters
The aim of this study was clearly stated on the online survey systems main web page and the
cover sheet of the printed version. Completing the questionnaire was deemed to constitute
consent. All respondents participated in this study without any incentive provided by the
study investigators. Similarly, all authors and subjects involved in this study declared
themselves free of any conflict of interest relating to the present study. The study protocol
(Shakaiteki Hikikomori Ni Kansuru Kenkyu) was approved by the ethics committee of
Sapporo Medical University, and this study was conducted in compliance with the Helsinki
Declaration.
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
8/14
Results
The results of the study are summarized in Table 1. Responses to the question regarding the
length of social withdrawal necessary for diagnosis of hikikomori showed a great diversity,
ranging from the longest of 6.853.9 months by psychiatrists to the shortest of 2.953.4
months by students. In response to many statements, answers revealed a certain amount of
consistency. When asked to respond to the statement, hikikomori is NOT a disorder, all
five groups scored less than three, suggesting that all five groups tended to disagree with the
statement. The lowest score was made by nurses (2.611.1) and the highest by students
(2.861.1). The typical image of hikikomori involving someone who shuts themself in their
room and rarely looks at other family members in their homes tended to be agreed with (all
five groups answered higher than three). The statement hikikomori individuals sometimes go
out for grocery stores and bookstores was agreed to on average by psychiatrists, clinical
psychologists and the others group but nurses and students on average disagreed. The
responses to the statement that hikikomori is closely related to school refusal showed strong
agreement amongst all five groups; from 3.890.9 by clinical psychologists to 4.120.9 bymedical doctors. The idea that recovery from hikikomori is possible also tended to be agreed
with though interestingly, the lowest score was observed among psychiatrists (3.670.8)
while the rest of the groups scored higher than four.
We asked psychiatrists and pediatricians what they felt would be the most applicable
psychiatric diagnosis of hikikomori according to the ICD-10 [25], with the option of choosing
it is not a psychiatric disorder and unsure. The results are shown in Table 2. 30% of
psychiatrists answered schizophrenia would be the most applicable psychiatric diagnosis for
hikikomori cases whereas half of the pediatricians chose neurotic, stress-related and
somatoform disorders which includes anxiety disorders such as social anxiety disorder or
adjustment disorder. It should also be noted that both psychiatrists and pediatricians answeredthat almost one fifth of hikikomori individuals could be diagnosed as having developmental
disorders.
Discussion
The goals of this study were two-fold: to gain a better understanding of the publics
perception of hikikomori, particularly in health care professionals, and to investigate the
difference in the possible underlying psychiatric conditions of hikikomori individuals.
The perception of hikikomori amongst study participants
Overall, the study participants tended to agree on many responses. This includes opinions on
hikikomori regarding school refusal, psychological factors, family environment, and whether
or not hikikomori is a disorder or is related to Japanese society. Prior to the Japanese
governments publication of the new hikikomori guidelines in 2010, there was no official
definition of hikikomori. The hikikomori phenomenon before that time was described
initially by Saitos book and was often cited as if it described formal diagnostic criteria.
Additionally, the idea of hikikomori was spread in popular media. Thus it is not surprising
that many respondents had similar opinions about hikikomori.
Some differences in opinion did exist in the results of the questionnaire. Psychiatrists andpsychologists tended to group together in their differences in opinion. They generally felt that
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
9/14
the length of social withdrawal felt to be sufficient for a hikikomori diagnosis was longer,
6.853.9 months in psychiatrists and 5.674.1 in psychologists. In contrast to this result,
students on average felt that much less time was needed for a diagnosis of hikikomori
(2.953.4 months), the most popular answer being one month (n=96, 41.9%). These results
indicate that other respondents had a lower threshold for what is considered an abnormal
amount of social withdrawal. The opinion that hikikomori individuals sometimes go out togrocery stores and bookstores was viewed differently by the respective groups. Psychiatrists
(3.521.1) and psychologists (3.611.1) tended to agree with this view. Nurses (2.911.3)
and students (2.861.2) tended to disagree, suggesting that their image of an individual with
hikikomori as someone who spends most of their time confined to his/her own room.
Psychiatrist and psychologists, as well as pediatricians, also tended to feel more strongly that
hikikomori was related to biological factors such as underlying psychiatric or developmental
disorders than the other respondents. Of note, both questions regarding occasional leaving of
ones room and underlying psychiatric diagnoses represent two significant differences
between the definition in the new guidelines and that of Saitos book in 1998. The definition
in the new guidelines allows for leaving ones home as long as it is without social interaction
and refers to the difficulties of excluding prodromal schizophrenia. The changes in theguidelines might account for the differences seen in the respondents on these two issues.
The final notable difference in opinions was observed in responses to the statement recovery
is possible in individuals with hikikomori. Though the average response of most groups was
four or five, psychiatrists on average scored lower than four (3.670.8). It is possible that
some individuals examined in psychiatric clinics were diagnosed with schizophrenia by
psychiatrists. Such cases might be perceived as having a greater difficulty in overcoming
their clinical symptoms.
Regarding the issue of school refusal, this criterion is well known to be closely related to
hikikomori [2]. Defined by the Ministry of Education, Culture, Sports, Science & Technology
in Japan, school refusal is a protracted absence from school, typically more than 30 days per
year, caused by psychological factors such as fear, anxiety, anger, and sense of refusal [26].
These feelings can cause emotional conflict and guilt about staying at home. This conflict
commonly presents with somatic complaints. In the present study, all five groups agreed with
the statement that school refusal closely relates to hikikomori, suggesting the importance of
school refusal in the concept of hikikomori. A follow-up study of students who refuse to go
to school by Saito et al. revealed that about ten percent of them evolve into hikikomori during
their youth [18]. Based on this data, the new hikikomori guidelines recommend early
intervention in school refusal in order to prevent development of hikikomori.
The biopsychosocial model is a well-known model which describes that biological,
psychological, and social factors, all play an important role in psychiatric conditions [27]. In
this study, biological factors include psychiatric disorders and developmental disorders,
psychological factors include difficulty in school such as being bullied, taunted, and refused
by school peers, or a sense of failure at their workplace, and social factors contain
environmental factors such as excessively protective parenting style and dysfunctional family
dynamics. The results in this study suggest that medical doctors regarded biological factors as
more important compared to other groups, while all groups thought that both psychological
and social factors were related to hikikomori.
In the final question of the survey, respondents tended to believe that hikikomori is related toJapanese culture and society. An international questionnaire survey by Kato et al. found that
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
10/14
Japanese psychiatrists tended to believe social and cultural factors played a larger role in
hikikomori than psychiatrists from other countries, and tended to be more passive in
providing medical intervention in hikikomori cases [15]. This passivity may be related to
amae, a Japanese word that describes dependent behaviors typically observed between
parents and their children, one of the factors believed to contribute to the Japanese cultural
acceptance of this phenomenon [28]. Individuals with a sense of amae may beg or plead,behave selfishly and indulgently, while secure in the knowledge that the caregiver will
forgive their acts. This concept ofamae might cause delay in help-seeking behavior of family
members of hikikomori subjects.
Underlying psychiatric disorders of hikikomori
Regarding the question of underlying psychiatric disorders in hikikomori, there is an ongoing
debate amongst parties consisting of three different views; 1) most hikikomori cases can be
diagnosed using existing ICD [25] or DSM [29] diagnostic criteria, 2) hikikomori is not a
psychiatric disorder and 3) hikikomori represents a new diagnostic category [30]. Kondo and
his group reported that most hikikomori cases can be diagnosed using current diagnostic
criteria [31]. One interpretation of the second view is that hikikomori is a culture-bound
syndrome [17]. The above debate raises questions about whether hikikomori is a mental
illness by itself. Though a case of hikikomori may be identifiable, caseness does not
necessarily guarantee the presence of mental illness [32] and in the case of hikikomori, may
imply the presence of numerous illnesses or none at all.
In this study, respondents tended to believe that hikikomori individuals could be diagnosed
with existing psychiatric diagnoses, specifically the F codes in chapter V of the ICD-10 [25].
Approximately 30% of psychiatrists chose F2 (Schizophrenia, schizotypal and delusional
disorders), the most commonly chosen diagnosis by psychiatrists. The most commonlychosen diagnosis amongst pediatricians at 50% was F4 (Neurotic, stress-related and
somatoform disorders). This difference in opinion might be explained by the difference in age
of the patients typically seen at their respective clinics.
It is noteworthy that both psychiatrists and pediatricians answered that almost one fifth of
their hikikomori patients could be diagnosed with F8 (Disorders of psychological
development) such as pervasive developmental disorders (PDD). Kondos survey cited in the
new guidelines [18] reports that among hikikomori cases who visited mental health centers in
five different prefectures in Japan, about 30% of them were diagnosed as having
developmental disorders . Recent epidemiological studies demonstrate that the number of
individuals with the diagnosis of PDD is rising [33-35]. The criteria for the diagnosis of PDDsuch as autism and Asperger's syndrome include: 1) qualitative impairment in social
interaction and 2) restricted, repetitive, and stereotyped patterns of behavior, interests, and
activities. Most hikikomori cases have difficulties in reciprocal social interaction. Thus, a co-
morbid diagnosis of PDD should be considered in individuals diagnosed with hikikomori and
a careful developmental history should be taken.
The results of the present study were similar to the results of previous epidemiological studies
in regards to the underlying psychiatric disorders of hikikomori [31]. In an investigation of
hikikomori youth (under 30 years old) who were referred to psychiatric emergency services,
the proportion of the diagnosis of psychiatric disorders coded in F2, F4 and F8 was almost
equal (Nakashimas survey cited in the guidelines [18]; unpublished). In a different study,psychiatric disorders were observed in 125 cases of severe social withdrawal. 27% of these
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
11/14
cases were diagnosed with developmental disorders such as PDD [30]. Other common
diagnoses included anxiety disorders (22%), personality disorders (18%), mood disorders
(14%) and psychosis (8%). In this study, it was concluded that hikikomori cases could be
divided into three groups: 1) patients with diagnoses such as schizophrenia, mood disorders,
anxiety disorders who might respond well to biological interventions (i.e.,
psychopharmacotherapy), 2) patients with developmental disorders such as PDD or mentalretardation for whom a more psychological approach including social skills training,
vocational training and utilization of social resources are needed, and 3) patients with
personality disorders, distortion of personality trait or identity problems and who may have
comorbid psychiatric disorders e.g. mood disorders or anxiety disorders for whom
psychotherapy, social and vocational support should be performed. Regarding subjects
categorized in the third group, it was warned that they may not respond well to
pharmacotherapy despite a primary diagnosis of mood disorder or anxiety disorder.
Study limitations
There were several limitations in this study. First, though the total number of subjects in this
study was higher than other previous surveys on hikikomori, we only drew from people with
health-related professions, smaller numbers of subjects were studied within some
professional subcategories, and we sampled within only a few areas of Japan making it
difficult to generalize the results. Second, we did not gather subjects demograph ic
information such as age and gender which may have helped to make inferences from the data.
Additionally we did not gather data on past history of the contact with hikikomori subjects.
The clinical and social experiences of the study subjects pertaining to previous contact with
hikikomori individuals could potentially have had a large influence on the answers to the
questionnaire.
Conclusion
The new Japanese government guidelines on hikikomori presented a definition of hikikomori
and recommended including the essential aspect of school refusal to the definition. This
definition describes the phenomenon in which a person becomes a recluse in his/her own
home, avoiding all kinds of social situations for at least six months. In children with school
refusal, various feelings can be observed that cause emotional conflict, ambivalence and guilt
against staying at home without going to school regardless of their superficial problems. It is
likely for such children to result in hikikomori. The prevention of hikikomori might be helped
with an intervention for school refusal. Support for hikikomori should be multi-dimensional
and comprehensive. Underlying psychiatric disorders including developmental disorders andpersonality disorders should be carefully assessed for and appropriate interventions should be
started promptly.
In conclusion, hikikomori describes a phenomenon characterized by severe social avoidance.
The findings suggest that cases of hikikomori can potentially be explained by other
underlying psychiatric disorders. Thus though a case of hikikomori may not represent a
unique mental illness, it potentially could be treated like R codes of the ICD-10 which
represent symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified. More studies are needed to further this discussion, particularly reports from other
countries.
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
12/14
Competing interests
The authors declare that they have no competing interests.
Authors contributionsMT and TWP contributed to the studys design. MT, TAK and WUN equally contributed to
data collection, and had full access to the data. TS supervised this study and manuscript
writing. MT drafted the manuscript. TWP assisted with drafting the manuscript. All authors
have read and approved this paper.
Acknowledgements
The authors thank Yasuyo Suzuki, Kiyoji Matsuyama (Sapporo Medical University), Takeshi
Ujiie (Hokkaido Ujiie Clinic for Psychosomatic Children) for their contributions for datacollection, and Ryuji Sasaki (Sapporo Medical University) for his technical assistance for on-
line questionnaire.
This study was partially supported by the World Psychiatric Association (WPA) Research
Fund 2010 to TAK.
References
1. Oxford Dictionaries: Oxford dictionary of english. 3rd edition. Oxford: OxfordUniversity Press; 2010.
2. Saito T: Shakaiteki hikikomori: owaranai shishunki (social withdrawal: a
neverending adolescence). Tokyo: PHP Shinsho; 1998.
3. Furlong A: The Japanese hikikomori phenomenon: acute social withdrawal among
young people.Sociol Rev 2008, 56(2):309325.
4. Garcia-Campayo J, Alda M, Sobradiel N, Sanz Abos B: A case report of hikikomori in
Spain.Med Clin (Barc) 2007, 129(8):318319.
5. Gariup M, Parellada E, Garcia C, Bernardo M: Hikikomori or simple schizophrenia?
Med Clin (Barc) 2008, 130(18):718719.
6. Sakamoto N, Martin RG, Kumano H, Kuboki T, Al-Adawi S: Hikikomori, is it a culture-
reactive or culture-bound syndrome? nidotherapy and a clinical vignette from Oman. Int J Psychiatry Med2005, 35(2):191198.
7. Watts J: Public health experts concerned about hikikomori. Lancet 2002,
359(9312):1131.
8. Krieg A, Dickie JR: Attachment and hikikomori: a psychosocial developmental model.
Int J Soc Psychiatry 2011, doi:10.1177/0020764011423182.
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
13/14
9. Nagata T, Yamada H, Teo AR, Yoshimura C, Nakajima T, Van Vliet I: Comorbid social
withdrawal (hikikomori) in outpatients with social anxiety disorder: clinicalcharacteristics and treatment response in a case series.Int J Soc Psychiatry 2011,
doi:10.1177/0020764011423184.
10. Borovoy A: Japan's hidden youths: mainstreaming the emotionally distressed inJapan.Cult Med Psychiatry 2008, 32(4):552576.
11. Zielenziger M: Shutting Out the Sun: How Japan created its own lost generation.
NewYork: Nan A. Talese; 2006.
12. Umeda M, Kawakami N, World Mental Health Japan Survey G: Association of
childhood family environments with the risk of social withdrawal (hikikomori) in the
community population in Japan.Psychiatry Clin Neurosci 2012, 66(2):121129.
13. Teo AR: Social isolation associated with depression: a case report of hikikomori.Int
J Soc Psychiatry 2012, doi:10.1177/0020764012437128.
14. Kato TA, Shinfuku N, Sartorius N, Kanba S: Are Japans hikikomori and depression
in young people spreading abroad?Lancet2011, 378(9796):1070.
15. Kato TA, Tateno M, Shinfuku N, Fujisawa D, Teo AR, Sartorius N, Akiyama T, Ishida T,
Choi TY, Balhara YP, et al: Does the hikikomori syndrome of social withdrawal exist
outside japan? a preliminary international investigation. Soc Psychiatry Psychiatr
Epidemiol2012, 47(7):10611075.
16. Teo AR: A new form of social withdrawal in Japan: a review of hikikomori. Int J Soc
Psychiatry 2010, 56(2):178185.
17. Teo AR, Gaw AC: Hikikomori, a japanese culture-bound syndrome of social
withdrawal?: a proposal for DSM-5.J Nerv Ment Dis 2010, 198(6):444449.
18. Saito K: Hikikomori no hyouka-shien Ni kansuru gaido-rain [guideline of
hikikomori for their evaluations and supports]. Tokyo: Ministry of Health, Labour and
Welfare; 2010.
19. Koyama A, Miyake Y, Kawakami N, Tsuchiya M, Tachimori H, Takeshima T: Lifetime
prevalence, psychiatric comorbidity and demographic correlates of hikikomori in acommunity population in Japan.Psychiatry Res 2010, 176(1):6974.
20. Cabinet-Office: Hikikomori chousa (hikikomori survey). Tokyo: The Cabinet Office of
the Japanese government; 2010.
21. Tateno M, Kato TA, Nakano W, Kanba S, Nakamura J, Saito T: Differences in the
preferred antipsychotics for acute schizophrenia among young psychiatrists in two
regions of Japan.Asian J Psychiatr2010, 3(2):6063.
22. Tateno M, Kato T, Nakano W, Teo AR, Nakagawa A, Kanba S, Nakamura J, Saito T:
Attitudes of early-career psychiatrists in Japan toward child and adolescent psychiatryand their career decision.Psychiatry Clin Neurosci 2010, 64(2):199201.
-
7/28/2019 Tateno, M. et. al. (2012) Hikikomori as a possible clinical term in psychiatry-A questionnaire survey
14/14
23. Tateno M, Sugiura K, Uehara K, Fujisawa D, Zhao Y, Hashimoto N, Takahashi H,
Yoshida N, Kato T, Nakano W, et al: Attitude of young psychiatrists toward coercive
measures in psychiatry: a case vignette study in Japan.Int J Ment Health Syst 2009,
3(1):20.
24. Tateno M, Uchida N, Kikuchi S, Kawada R, Kobayashi S, Nakano W, Sasaki R, ShibataK, Shirasaka T, Suzuki M, et al: The practice of child and adolescent psychiatry: a survey
of early-career psychiatrists in Japan. Child Adolesc Psychiatry Ment Health 2009,
3(1):30.
25. WHO: The ICD-10 classification of mental and behavioural disorders: clinical
descriptions and diagnostic guidelines. Geneve: World Health Organization; 1992.
26. Honjo S, Nishide T, Niwa S, Sasaki Y, Kaneko H, Inoko K, Nishide Y: School refusal
and depression with school inattendance in children and adolescents: comparative
assessment between the childrens depression inventory and somatic complaints.
Psychiatry Clin Neurosci 2001, 55(6):629634.
27. Engel GL: The need for a new medical model: a challenge for biomedicine. Science
1977, 196(4286):129136.
28. Doi T: The anatomy of dependence. New York: Kodansha USA; 2002.
29. APA: Diagnostic and statistical manual of mental disorders DSM-IV fourth edition.
Washington, DC: American Psychiatric Publishing, Inc; 1994.
30. Kondo N, Kiyota Y, Kitahashi Y: Psychiatric background of social withdrawal in
adolescence.Seishin Shinkeigaku Zasshi 2007, 109(9):834843.
31. Kondo N, Sakai M, Kuroda Y, Kiyota Y, Kitabata Y, Kurosawa M: General condition of
hikikomori (prolonged social withdrawal) in Japan: psychiatric diagnosis and outcome
in mental health welfare centres. Int J Soc Psychiatry 2012,
doi:10.1177/0020764011423611.
32. Kato M: Seishinshougai ni okeru jireisei (caseness in mental impairment). Seishin
Igaku (Clinical Psychiatry) 1966, 8(7):523524.
33. Brugha TS, McManus S, Bankart J, Scott F, Purdon S, Smith J, Bebbington P, Jenkins R,Meltzer H: Epidemiology of autism spectrum disorders in adults in the community in
England.Arch Gen Psychiatry 2011, 68(5):459465.
34. Kurita H: Disorders of the autism spectrum.Lancet2006, 368(9531):179181.
35. Baron-Cohen S, Scott FJ, Allison C, Williams J, Bolton P, Matthews FE, Brayne C:
Prevalence of autism-spectrum conditions: UK school-based population study.Br J
Psychiatry 2009, 194(6):500509.